REASSIGNMENT OF MEDICARE BENEFITS CMS-855R

1 MEDICARE ENROLLMENT APPLICATION REASSIGNMENT OF MEDICARE BENEFITS CMS-855R SEE PAGE 2 FOR INFORMATION ON WHERE TO MAIL THIS APPLICATION. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0685 GENERAL INFORMATION Physicians and non-physician practitioners can reassigning MEDICARE payments or terminate a REASSIGNMENT of MEDICARE BENEFITS after enrollment in the MEDICARE program or make a change in their REASSIGNMENT of MEDICARE benefit information using either: The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or The paper enrollment application process ( , CMS 855R). For additional information regarding the MEDICARE enrollment process, including Internet-based PECOS, go to NOTE: Physicians and non-physician practitioners who are enrolled in the MEDICARE program, but have not submitted the CMS 855I since 2003, are required to submit a MEDICARE enrollment application ( , Internet-based PECOS or the CMS 855I) as an initial application prior to completing a CMS 855R application.

2 Complete this application if you are reassigning your right to bill the MEDICARE program and receive MEDICARE payments, or are terminating a REASSIGNMENT of BENEFITS . Reassigning your MEDICARE BENEFITS allows an eligible supplier to submit claims and receive payment for MEDICARE Part B services that you have provided. Such an eligible supplier may be an individual, a clinic/group practice or other organization. Both the individual practitioner and the eligible supplier must be currently enrolled (or concurrently enrolling via submission of the CMS-855B for the eligible supplier and the CMS-855I for the practitioner) in the MEDICARE program before the REASSIGNMENT can take effect. Generally, this application is completed by a supplier, signed by the individual practitioner, and submitted by the supplier. When terminating a current REASSIGNMENT , either the supplier or the individual practitioner may submit this application with the appropriate sections completed. The individual or authorized/delegated official, by his/her signature, agrees to notify the MEDICARE fee-for-service contractor of any future changes to the REASSIGNMENT in accordance with 42 (d)(2).

3 NOTE: An individual will not need to reassign BENEFITS to a corporation, limited liability company, professional association, etc., of which he/she is the sole owner. See the CMS-855I Application for Physicians and Non-Physician Practitioners for more information. NOTE: PHySICAIN ASSISTANTS: This application should not be used to report employment arrangements. Employment arrangements must be reported in Sections 2E through 2G of the CMS-855I application. INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION Type or print all information so that it is legible. Do not use pencil. Sign and date the certification statement. Keep a copy of your completed MEDICARE enrollment package for your own records and for updating your information. Send the completed application with original signatures and all required documentation to your designatedMedicare fee-for-service contractor. CMS-855R (07/11) 1 ADDITIONAL INFORMATION The information you provide on this form will not be shared.

4 It is considered to be protected under 5 552(b)(4) and/or (b)(6), respectively. For more information, see the Privacy Act Statement located at the end of this application. For additional information regarding the MEDICARE enrollment process, visit MedicareProviderSupEnroll. The NPI is the standard unique health identifier for health care providers and is assigned by the National Plan and Provider Enumeration System (NPPES). As a MEDICARE health care supplier, you must obtain an NPI prior to enrolling in MEDICARE or before submitting a change to your existing MEDICARE enrollment information. Applying for the NPI is a process separate from MEDICARE enrollment. To obtain an NPI, you may apply online at For more information regarding NPI enumeration, visit The MEDICARE Identification Number is a generic term for any number, other than the NPI, that is used to identify a MEDICARE supplier. MAIL YOUR APPLICATION The MEDICARE fee-for-service contractor that services your State is responsible for processing your enrollment application.

5 If you do not know who your fee-for-service contractor is, you can locate it on the Centers for MEDICARE & Medicaid Services (CMS) web site at CMS-855R (07/11) 2 SECTION 1: BASIC INFORMATION ADDING A NEW REASSIGNMENT If you are: Enrolling for the first time in the MEDICARE program (and have completed the CMS-855I) and are reassigning your BENEFITS to an eligible supplier. Currently enrolled in the MEDICARE program and are reassigning your BENEFITS to an eligible supplier. NOTE: The supplier must be enrolled or currently enrolling in MEDICARE (submitting the CMS-855B and/or CMS-855I) before the REASSIGNMENT can take effect. TERMINATING A CURRENT REASSIGNMENT If you are an: Individual practitioner who is terminating a REASSIGNMENT of BENEFITS to the supplier identified in Section 2. No reassigned claims will be paid to the supplier for services rendered by the practitioner after the effective date of deletion. Organization that is terminating a REASSIGNMENT of BENEFITS from the individual practitioner identified in Section 3.

6 No reassigned claims will be paid to the supplier for services rendered by the practitioner after the effective date of deletion. NOTE: When adding a REASSIGNMENT , Section 4A must be completed by the individual practitioner and Section 4B must be completed by an authorized or delegated official of the supplier. (If the supplier is an individual, that person must sign Section 4B.) When terminating a REASSIGNMENT , either Section 4A must be completed by the individual practitioner or Section 4B must be completed by an authorized or delegated official of the supplier. CMS-855R (07/11) 3 SECTION 1: BASIC INFORMATION ALL APPLICANTS MUST COMPLETE THIS SECTION Check the applicable box and complete the required sections. REASON FOR APPLICATION PROVIDE INFORMATION REQUIRED SECTIONS You are enrolling or are currently enrolled in MEDICARE and will be reassigning yourbenefits to this supplier for the first time Effective Date (mm/dd/yyyy): Complete all sections You are an individual practitioner terminating a REASSIGNMENT Effective Date (mm/dd/yyyy): Sections 1, 2, 3, 4A, and 7 You are the organization terminatinga REASSIGNMENT Effective Date (mm/dd/yyyy): Sections 1, 2, 3, 4B, and 7 CMS-855R (07/11) 4 SECTION 2: ORGANIZATION RECEIVING THE REASSIGNED BENEFITS Organization/Group IdentificationProvide the requested information below for the supplier to whom BENEFITS are being reassigned, or with whom a REASSIGNMENT is being terminated.

7 If the supplier s initial enrollment application is being submitted concurrently with this REASSIGNMENT application, write pending in the MEDICARE identification number block. The supplier s name as reported to the IRS must be the same as reported on the supplier s CMS-855B when it enrolled. Supplier s Legal Business Name (as Reported to the Internal Revenue Service) Tax Identification Number MEDICARE Identification Number (if issued) National Provider Identifier SECTION 3: INDIVIDUAL PRACTITIONER WHO IS REASSIGNING BENEFITS Individual Practitioner Identification Provide the information below for the individual who will be reassigning his/her BENEFITS to this supplier, or who will be terminating such a REASSIGNMENT . If your initial enrollment application is being submitted concurrently with this REASSIGNMENT application, write pending in the MEDICARE identification number block. First Name Middle Initial Last Name Jr., Sr., , , etc. Social Security Number MEDICARE Identification Number (if issued) National Provider Identifier CMS-855R (07/11) 5 SECTION 4: AUTHORIZATION STATEMENTS The signatures below authorize the REASSIGNMENT of BENEFITS to a supplier or the termination of a REASSIGNMENT of BENEFITS to a supplier, as indicated in Section 1.

8 Title XVIII of the Social Security Act prohibits payment for services provided by an individual practitioner to be paid to another individual or supplier unless the individual practitioner who provided the services specifically authorizes another individual or supplier (employer, facility, or health care delivery system) to receive said payments in accordance with 42 and 42 By signing this REASSIGNMENT of BENEFITS Statement, you are authorizing the supplier identified in Section 2 to receive MEDICARE payments on your behalf. Your employment or contract with this individual or supplier must be in compliance with CMS regulations and you must be in compliance with applicable MEDICARE program safeguard standards described in 42 All individual practitioners who allow another supplier (employer, facility, or health care delivery system) to receive payment for their services must sign the REASSIGNMENT of BENEFITS Statement. The signatures below acknowledge that you will abide by all laws and regulations pertaining to the REASSIGNMENT of BENEFITS .

9 A. Individual Practitioner I certify that I have examined the above information and that it is true, accurate and complete. I understand that any misrepresentation or concealment of any information requested in this application may subject me to liability under civil and criminal laws. Individual Practitioner First Name Middle Initial Last Name Jr., Sr., , , etc. Individual Practitioner Signature (First, Middle, Last Name, Jr., Sr., , , etc.) Date Signed (mm/dd/yyyy) B. Authorized or Delegated Official of Group Practice/Clinic I certify that I have examined the above information and that it is true, accurate and complete. I understand that any misrepresentation or concealment of any information requested in this application may subject me to liability under civil and criminal laws. First Name Middle Initial Last Name Jr., Sr., , , etc. Authorized or Delegated Official s Signature (First, Middle, Last Name, Jr., Sr., , , etc.) Date Signed (mm/dd/yyyy) All signatures must be original and signed in ink.

10 Applications with signatures deemed not original will not be processed. Stamped, faxed or copied signatures will not be accepted. CMS-855R (07/11) 6 SECTION 5: FOR FUTURE USE (THIS SECTION NOT APPLICABLE) SECTION 6: FOR FUTURE USE (THIS SECTION NOT APPLICABLE) SECTION 7: CONTACT PERSON This section captures information regarding the person you would like for us to contact regarding thisapplication. First Name Middle Initial Last Name Jr., Sr., etc. Address Line 1 (Street Name And Number) Address Line 2 (Suite, Room, etc.) City/Town State Zip Code +4 Telephone Fax Number (optional) Email Address (if available) According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0685. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.